Emerging Infectious DiseasesDonna Gallagher,

PhD, ANP-C,MS, FAAN

PI, NEAETC

Lancet

recent emerging diseases

Emerging and re-emerging infectious diseases

• AIDS

• Avian Influenza

• Ebola

• Marburg

• Cholera

• Rift Valley Fever

• Typhoid

• Lassa Fever

• Tuberculosis

• Leptospirosis

• Malaria

• Japanese encephalitis

• Chikungunya

• Dengue

• Antimicrobial resistance

• MERS

Factors contributing to emergence

AGENT

• Evolution of pathogenic infectious agents (microbial adaptation & change)

• ex: influenza

• Development of resistance to drugs • ex: MRSA, KPC

• Resistance of vectors to pesticides• ex: malaria

Factors contributing to emergence

HOST

» Human demographic change (inhabiting new areas)

» Human behaviour (sexual & drug use)

» Human susceptibility to infection (Immunosuppression)

» Poverty & social inequality

Factors contributing to emergence

ENVIRONMENT

»Climate & changing ecosystems

»Economic development & Land use (urbanization, deforestation)

»Technology & industry (food processing & handling)

Transmission of Infectious Agent from Animals to Humans

• Emerging Influenza infections in Humans associated with Geese, Chickens & Pigs

• Animal displacement in search of food after deforestation/ climate change (Lassa fever)

• Humans themselves penetrate/ modify unpopulated regions- come closer to animal reservoirs/ vectors (Yellow fever, Malaria)

Dr. KANUPRIYA CHATURVEDI

Emerging Zoonoses: Human-animal interface

Marburg virus

Hantavirus Pulmonary Syndrome

Ebola virus

Borrelia burgdorferi: Lyme Deer tick Mostomysrodent: Lassa

fever

Avian influenza virus

Bats: Nipahvirus

Pandemic and Epidemic Diseases department - 9

How Ebola Outbreaks Start

●First human cases start with infection by an animal ●Bats to chimpanzes, other animals and bush meat. How current

outbreak started in unknown, but killing and preparing bush meat can spread other viral illnesses

●Infection from person-to-person creates an outbreak• Direct or indirect physical contact with body fluids of a sick

infected person (blood, saliva, vomitus, urine, stool, semen)

●Well known locations where transmission occurs• Hospital:

• Health care workers, other patients, unsafe injections

• Houses and Communities:

• Family, friends, contacts caring for ill, through funeral practices---ie contact with dead bodies

Pandemic and Epidemic Diseases department - 10

Critical Issues

● First large Ebola outbreak in West Africa

● Underlying weakness in health systems

● Lack of preparedness and poor surveillance, health care, diagnostics, communications …

• Health worker infections & inadequate infection control & prevention The affected countries in West Africa have some of the worst physician–patient ratios in the world:

– Liberia: more than 86 000 patients per physician

– Sierra Leone: more than 45 000 patients per physician

Effect of fear

● Strong community resistance in places ……..

Training ………… screening

PPE, Bleach water (0.5% and 0.05%) Triage, Isolation, and No

Touch Care!

Lab tech in the clinic MOH Triage Flow Chart USA PPE

US

• Contact Precautions

• Working knowledge of emerging diseases

• Know where your PPE is located

• Know who to call

• Don’t Panic

EMERGING INFECTIONS: STANDARD AND TRANSMISSION-BASED PRECAUTIONS FOR AMBULATORY HEALTHCARE SETTINGS

Kathy Eklund RDH, MHP

The Forsyth Institute

keklund@forsyth.org

Disclosures

Disclosure: Neither I nor members of my immediate family have any financial relationships with commercial entities that may be relevant to

this presentation.Visuals of products and devices are examples and

are not an endorsement.

Objectives

• Differentiate standard and transmission-based precaution measures

• Identify measures and resources clinicians may use to promote respiratory hygiene and setting-specific illness recognition.

What is an Infection Prevention and Control Program?

A system of policies, procedures and practices that when successfully implemented, will minimize the risk of transmission of pathogenic microorganisms. The goal is to prevent:

– healthcare-associated infections in patients

– injuries and illnesses in healthcare personnel

Public Trust & Expectations

Infection Prevention and Control Program

Professional Standards, Best Practices

Regulations, Guidance, Standards

IndividualProvider,Practice,Institution(SOPs, Ethics)

Patient &Personnel Safety

Infection Control Policies and Procedures..

• Should be supported by an authoritative source

The Chain of Infection

Standard Precautions

Sterilization

Vaccination

Hand Hygiene

PPE

Portal of Entry

Mucos Membrane GI Tract

Respiratory Broken Skin

Pathogens of Sufficient

Virulence and Numbers

to Cause Infection

Susceptible Host

One who is not immune

Mode of Transmission

Direct or indirect Contact

Droplet Airborne

Reservoir or Source

Blood, Water

Break the Chain

Summary

A variety of infectious agents can be transmitted in ambulatory healthcare settings through contact, droplet and airborne modes

Standard precautions remain the major infection prevention strategy to prevent transmissions

Hepatitis B and C virus transmission in healthcare remain preventable risks

Standard Precautions

• Synthesize major features of Universal Precautions

– Applies to all patients regardless of diagnosis or infection status

– Includes blood and all body fluids except sweat (includes saliva in all settings)

• May be supplemented by special isolation precautions for diseases transmitted by contact, droplet or airborne routes

Guideline for Isolation Precautions in Hospitals

Epidemiol 1996;17:53-80, and Am J Infect Control 1996;24:24-52.

Standard Precautions

• MUST be used in the care of all patients regardless of their infection status.

• Some patients require additional measures = ‘transmission-based precautions’– Interrupt potential spread of diseases via

airborne, droplet, or contact transmission.

– e.g. TB, influenza, and chickenpox

– Spread via coughing, sneezing or contact with skin.

CDC 2007 Guideline for Isolation Precautionshttp://www.cdc.gov/ncidod/dhqp/pdf/isolation2007.pdf.

Transmission-Based Precautions

Pathogen and syndrome-based precautions, termed transmission-based precautions, for the care of patients who are infected or colonized with pathogens spread through airborne, droplet, or contact routes.

• Standard Precautions +…..

CDC 2007 Guideline for Isolation Precautionshttp://www.cdc.gov/ncidod/dhqp/pdf/isolation2007.pdf. Guidelines for infection control in dental health-care settings—2003. http://www.cdc.gov/mmwr/PDF/rr/rr5217.pdf

Standard Precautions +

TRANSMISSION-BASED PRECAUTIONS

• Transmission-based precautions are designed for patients documented or suspected to be infected or colonized with pathogens that require additional precautions beyond the standard precautions necessary to interrupt transmission.

• These precautions apply to airborne, droplet, and contact transmissions. The precautionsmay be combined for diseases that have multiple routes of transmission.

• Whether singly or in combination, they are always to be used in addition to standard precautions.

Transmission-Based Precautions• Might include:

• Patient placement (e.g., isolation)

• Adequate room ventilation

• Respiratory protection (e.g., N-95 masks) for dental health-care personnel (DHCP)

• Postponement of nonemergency dental procedures.

• More than 1 transmission category may apply

• Always used IN ADDITION to Standard Precautions

CDC 2007 Guideline for Isolation Precautionshttp://www.cdc.gov/ncidod/dhqp/pdf/isolation2007.pdf. Guidelines for infection control in dental health-care settings—2003. http://www.cdc.gov/mmwr/PDF/rr/rr5217.pdf

Contact PrecautionsContact transmission, the most important and frequent mode of transmission of heahcare-associated infections, is divided into two subgroups:

direct-contact transmission

indirect-contact transmission

Example: MRSA

Contact: Droplet Precautions• Droplet transmission,

theoretically, is a form of contact transmission. However, the mechanism of transfer of the pathogen to the host is quite distinct from either direct- or indirect-contact transmission. Therefore, droplet transmission is considered a separate route of transmission

• Examples:– Influenza– Chickenpox

Airborne Precautions• Airborne transmission

occurs by dissemination of either airborne droplet nuclei (small-particle residue [5 µm or smaller] of evaporated droplets containing microorganisms that remain suspended in the air for long periods) or dust particles containing the infectious agent.

• Tuberculosis (TB)

2014 Ebola Outbreak Response

West Africa

• Centers for Disease Control and Prevention

• Ebola Response 2014

2014 Ebola Outbreak

Healthcare Providers in the United States CDC encourages all U.S. healthcare providers to:

Ask patients about their travel histories to determine if they have traveled to West Africa within the last three weeks

Know the signs and symptoms of Ebola – fever (greater than 100.4°F or 38°C), severe headache, muscle pain, vomiting, diarrhea, abdominal (stomach) pain, or unexplained hemorrhage (bleeding or bruising)

Know what to do if they have a patient with Ebola symptoms:

• First, properly isolate the patient

• Then, follow infection control precautions to prevent the spread of Ebola.

• Avoid contact with blood and body fluids of infected people

Infection Control Principles

Early recognition Early recognition is critical for infection control

Patient Placement Patients should be placed in a single patient room containing a

private bathroom with the door closed

Protecting healthcare providers IDENTIFY-ISOLATE-INFORM

Guidance for hospitals available at: http://www.cdc.gov/vhf/ebola/hcp/infection-prevention-and-control-recommendations.html

Guidance for emergency departments available at: http://www.cdc.gov/vhf/ebola/hcp/ed-management-patients-possible-ebola.html

Guidance for ambulatory care settings in development

Elements of Standard Precautions

• Handwashing

• Personal protective equipment

• Sterilization of instruments and devices

• Cleaning/disinfecting environmental surfaces

• Engineering/work practice controls

• Respiratory hygiene/cough etiquette

• Safe injection practices

CDC 2007 Guideline for Isolation Precautionshttp://www.cdc.gov/ncidod/dhqp/pdf/isolation2007.pdf.

Acknowledge:CAPT Raymond A. Strikas, MD, MPH, FACP, FIDSASarah Schillie, MD, MPH, MBA

www.cdc.gov/mmwr/preview/mmwrhtml/rr6007a1.htm?s_cid=rr6007a1_e

Immunization of Health-Care Personnel

2012 ACIP Adult Immunization Schedule, Medical, Occupational and Behavior-Based

Recommendations

Recommended Vaccines for HCP Based on Risk of Healthcare Setting Transmission*

*MMWR November 25, 2011 / 60(RR07);1-45

Hepatitis B Give 3-dose series. Give IM. Obtain anti-HBs serologic

testing 1-2 months after dose #3

Influenza Give 1 dose of TIV or LAIV annually. Give TIV

intramuscularly or LAIV intranasally. Follow 2013

recommendations from CDC

MMR HCP born in 1957 or later without evidence of immunity

or prior vaccination, give 2 doses MMR, 4 weeks apart.

Give SC. If born before 1957, 1 dose. Two doses for all

HCP during mumps outbreak.

Varicella HCP with no serologic proof of immunity, prior

vaccination, or history of varicella disease, give 2

doses of varicella vaccine, 4 weeks apart. Give SC.

Tetanus/diph-

theria/pertussis

All HCP need Td every 10 years after completing a

primary series. Give 1 dose of Tdap IM, if direct patient

contact, prioritize HCP in contact with pts. <12 mos.

39

CDC Recommendations for Hepatitis B Protection among HCP

(2013)

www.cdc.gov/mmwr/preview/mmwrhtml/rr6210a1.htm?s_cid=rr6210a1_w

HCP with Hepatitis B Vaccination in the Remote Past

40

Increasing proportion of HCP entering training and workforce have received HepB vaccination as infants or in the remote past

Anti-HBs testing not recommended after routine infant HepB vaccination

Anti-HBs after vaccination wanes over time, although protection believed to persist

HCP with Hepatitis B Vaccination in the Remote Past

(with Documentation of Complete, ≥3-dose HepB vaccine series)

41

May undergo anti-HBs testing upon hire or matriculation

Anti-HBs ≥10 mIU/mL: Considered immune

Anti-HBs <10 mIU/mL: 1 additional dose of HepBvaccine, followed by anti-HBs testing 1-2 months later

• HCP whose anti-HBs remains <10 mIU/mL should receive 2 additional doses (usually 6 doses total), followed by repeat anti-HBs testing 1-2 months after last dose

Pre-exposure anti-HBs Testing HCP Vaccinated in the Remote Past

42

~72% of institutions measure anti-HBs upon hire/matriculation for remotely vaccinated HCP

Advantages

Results in fewer cases of occupational Hepatitis B

transmission

Provides greatest protection for HCP (including protection against unrecognized/unreported exposures)

More cost-effective over time • 2013 MMWR

INFLUENZA VACCINE

Tools for the Prevention of Influenza

Influenza vaccine

Antiviral medications Can be used for treatment or prevention (prophylaxis)

Hand hygiene

Masks

Respirators

Environmental controls E.g. ensuring appropriate ventilation, air exchange, physical

barriers, etc.

Influenza Vaccine

Primary means for preventing influenza

Recommended annually for all people 6 months of age and older Including pregnant women

Including healthcare personnel

“Insurance” against infection

Benefit to those vaccinated plus decreases risk of spreading influenza to others Not 100% effective

Need to use other tools in addition to vaccination

Influenza and Vaccination

Four types of influenza vaccines available:

Traditional inactivated (“killed”) influenza vaccine injected in muscle • anyone 6 months of age or older

Nasal spray vaccine (LAIV): healthy individual• ages 2-49 years

• HCP not working with patients in a protected environment

High-dose inactivated injectable vaccine • 65 years and older

Intradermal inactivated vaccine: uses very small needle• 18-64 years old

Influenza and Mask or Respirator Use

Relatively few clinical studies done to assess reduction in influenza illness in clinical setting for masks or respirators

Household transmission studies and one study of college students found

Limited reductions with mask +/- hand hygiene when

• High levels of compliance with mask use

• Early initiation of mask use

No reductions in influenza with increase in hand hygiene alone

Study of 2009 H1N1 in hospital workers

Masks likely helpful

Emergency Department workers more likely to become ill with influenza than other types of workers

• May have been related to lack of wearing mask with first encounter with patient

Apisarnthanarak CID 2012; Vanhems Archives Intern Med 2011; Aiello JID 2010; Cowling Epi Infect 2010; Aiello AJPH 2008

Influenza vaccination coverage of health care personnel by occupation, mid-November 2011

† "Other" includes allied health professionals, technicians/assistants and aides, and administrative and non-clinical support staff.

Group Already vaccinated

Overall 63.4

Occupation:

Physician/dentist 77.6

Nurse practitioner/physician assistant 76.8

Nurse 75.7

Other† 58.7

http://www.cdc.gov/flu/professionals/vaccination/health-care-personnel.htm

Conclusions for Influenza

Many tools for influenza prevention, but vaccination is the primary means to prevent influenza

Best insurance against influenza infection and transmission to HCP family, friends, coworkers and patients

Vaccination should be used in conjunction with other influenza prevention tools to most effectively decrease the spread of influenza

Common Reasons HCP and Adult Patients Might Give for Not Getting Vaccinated

10. Vaccine preventable diseases are a thing of the past.

9. Vaccines don’t work.

8. I am great at washing my hands.

7. I always put on a mask before I am near patients that may have [INSERT DISEASE HERE].

6. I never come to work sick.

5. Vaccines will make me sick.

4. It is easier to deal with the rare case than to vaccinate routinely.

3. My patients are already vaccinated so I don’t need to be.

2. The healthcare facility where I work doesn’t require vaccines.

1. My doctor didn’t recommend any vaccines for me.

Summary

Outbreaks of vaccine preventable diseases continue to occur

Result in health risks to patients and HCP and their families

Very disruptive and expensive to investigate and manage

Can be difficult to recognize early and before many people have been exposed

Exposures and illnesses can result in substantial lost work time as early awareness and implementation of control measures challenging

Conclusions

Vaccines have been highly successful in reducing the burden of many diseases

Vaccination are a critical component of infection control to protect HCP and their patients, coworkers and families

DHCP should be

Assessed for vaccination and immunity status at the time of hire and at least annually to ensure they are up to date with recommended vaccines.

Provided with information about risks and benefits of the vaccines

Tuberculin Skin Test

TB Blood Test

Identifies if a person was exposed to MTB

Primed peptide TH1 cells create interferons

TB Testing Frequency

Risk category Frequency

Low Baseline on hire; further

testing not needed unless

exposure occurs

Medium Baseline, then annually

Potential ongoing

transmission

Baseline, then every 8–10

wks until evidence of

transmission has ceased

Program Evaluation: Immunization of HCP

• Program Element

– Appropriate immunization of health-care personnel (HCP).

• Develop and implement a program that promotes immunity of health-care personnel according to current CDC ACIP recommendations for health-care personnel.

– HBV Vaccine: OSHA Bloodborne Pathogens Standard Regulate Employer provide Education and Training, access to HBV vaccine during normal working hours, and pay for the vaccine. If employee refuses, the OSHA Declination form must be signed, but employee can change his/her mind.

– Other CDC recommended vaccines………

• Evaluation Activity

– Conduct an annual review of personnel records to ensure up-to-date immunizations.

• Keep updated immunization records of personnel.

• Refer non-immune personnel to a qualified health-care provider for evaluation and indicated vaccinations/immunizations.

Work Restrictions of HCP

Medical Conditions, Work-Related Illness,

and Work Restrictions

• HCP are responsible for monitoring their own health status. HCP who have acute or chronic medical conditions that render them susceptible to opportunistic infection should discuss with their personal physicians or other qualified authority whether the condition might affect their ability to safely perform their duties.

• Under certain circumstances, health-care facility managers might need to exclude HCP from work or patient contact to prevent further transmission of infection (e.g., conjunctivitis, influenza, etc.)

Medical Conditions, Work-Related Illness, and Work Restrictions

• Under certain circumstances, health-care facility managers might need to exclude HCP from work or patient contact to prevent further transmission of infection (e.g., conjunctivitis, influenza, etc.)

• Managers may exclude HCP from patient contact to prevent transmission

– Work restrictions based on mode of transmission and period of infectivity

– Written policies should define who can exclude HCP (e.g., personal physicians) and be clearly communicated

Medical Conditions, Work-Related Illness, and Work Restrictions

Decisions concerning work restrictions are based on the mode of transmission and the period of infectivity of the disease.

Medical Conditions, Work-Related Illness and Work Restrictions

• Exclusion policies should

– 1) be written,

– 2) include a statement of authority that defines who can exclude DHCP (e.g., personal physicians), and

– 3) be clearly communicated through education and training. Policies should also encourage DHCP to report illnesses or exposures without jeopardizing wages, benefits, or job status.

Medical Conditions, Work-Related Illness and Work Restrictions

Policies should encourage DHCP to report illnesses or exposures without jeopardizing wages, benefits, or job status.

Work Restrictions: Influenza• Self-assess daily for symptoms

of febrile respiratory illness (fever plus one or more of the following:

– nasal congestion/runny nose,

– sore throat

– cough.

• Personnel who develop fever and respiratory symptoms should promptly notify their supervisor and should not report to work.

Work Restrictions - Influenza

Personnel should remain at home until at least 24 hours after they are free of fever (100°F/37.8°C), or signs of a fever, without the use of fever-reducing medications.

Resource: Preventing Transmission of Influenza in Healthcare Settings

• http://www.cdc.gov/flu/pdf/infectioncontrol_seasonalflu_ICU2010.pdf

• On July 29, 2010, CDC issued Recommendations for the Prevention and Control of Influenza

• http://www.cdc.gov/flu/professionals/infectioncontrol/healthcaresettings.htm

• http://www.cdc.gov/flu/professionals/infectioncontrol/

Diseases for Which Vaccines Routinely Recommended for HCP and Work Implications if

Exposed* or InfectedMeasles Mumps Rubella Varicella Pertussis

if exposed and not immune

5 days after exposure through 21 days

12 days afterexposure through 25 days

7 days after exposurethrough 23 days

8 days after exposurethrough 21/28 days**

Monitor for cough for 21 days; consider antibiotics

if ill For 4 days after rashfirst appears

For 5 days after onset parotitis

For 7 days after rash first appears

Until all lesions dryand crust or no new lesions >24 hours

3 weeks after cough onset or 5 days antibiotics

Vaccine Doses***

2 SQ MMR doses

2 SQ MMR doses

1 SQ MMR dose

2 SQ One Tdapas adult

*Exposures are from first exposure through date of last exposure. **Longer if receive immune globulin; ***for MMR and Varicella is no accepted evidence of immunity.

CDC. Immunization of Health-care Personnel: Recommendations of the Advisory Committee on Immunization Practices. MMWR 2011;60:RR1-47.

Program Evaluation: Immunization of DHCP

• Program Element– Appropriate immunization of dental health-care

personnel (DHCP). • Develop and implement a program that promotes immunity of

health-care personnel according to current CDC ACIP recommendations for health-care personnel.

– HBV Vaccine: OSHA Bloodborne Pathogens Standard Regulate Employer provide Education and Training, access to HBV vaccine during normal working hours, and pay for the vaccine. If employee refuses, the OSHA Declination form must be signed, but employee can change his/her mind.

– Other CDC recommended vaccines………

• Evaluation Activity– Conduct an annual review of personnel records to

ensure up-to-date immunizations.• Keep updated immunization records of personnel.

• Refer non-immune personnel to a qualified health-care provider for evaluation and indicated vaccinations/immunizations.

Hand Hygiene/Antisepsis for Routine Dental Procedures

Soap &

Water

Anti-microbial

Soap & Water

Alcohol-based

Hand Rub

Alone

If hands are visibly

soiled with blood,

body fluids, or

proteinaceous

material

YES YES NO

If hands are not

visibly soiled YES YES YES

In the News…

December 13, 2013

70

• FDA issues proposed rule to determine safety and effectiveness of over the counter antibacterial soaps

– http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm378542.htm

– proposed rule to require manufacturers of antibacterial hand soaps and body washes to demonstrate that their products are safe for long-term daily use and more effective than plain soap and water in preventing illness and the spread of certain infections.

– Under the proposal, if companies do not demonstrate such safety and effectiveness, these products would need to be reformulated or relabeled to remain on the market.

Hand Hygiene/AntisepsisSurgical Procedures

Soap &

Water

Alone

Antiseptic

Handwash*& Water

Antiseptic

Handwash &

Water Followed

by Alcohol-

based Hand

Rub*

Surgical hand

antisepsis prior to

gloving

NO YES YES

* Antiseptic handwash agent and alcohol-based hand

rubs should have a persistent effect and broad spectrum of activity, and be fast-acting.

PPE

• Wear long-sleeved disposable or reusable gowns, lab coats, or uniforms that cover skin and personal clothing likely to be soiled with blood, saliva or infectious material

• Change if visible soiled, or as soon as possible

• Remove all barriers before leaving patient care or laboratory areas

72

73http://www.cdc.gov/vhf/ebola/pdf/ppe-poster.pdf

New Elements to Standard Precautions (2007)

• ‘Infection control problems that are identified in the course of outbreak investigations often indicate the need for new recommendations or reinforcement of existing infection control recommendations to protect patients.’

• Two areas of practice relevant to dentistry added:

– Respiratory Hygiene/Cough Etiquette

– Safe Injection Practices

CDC 2007 Guideline for Isolation Precautionshttp://www.cdc.gov/ncidod/dhqp/pdf/isolation2007.pdf.

Respiratory Hygiene/Cough Etiquette

• Grew out of observations during severe acute respiratory syndrome (SARS) outbreaks where failures to implement simple source control measures with patients, visitors, and health-care personnel with respiratory symptoms may have contributed to SARS-coronavirus (SARS-CoV) transmission.

• Conclusions of the investigations of transmissions that could have been prevented by adherence to basic principals of aseptic technique for the preparation and administration of parenteral medications

Safe Injection Practices

Respiratory Hygiene/Cough Etiquette

• Cover your mouth and nose with a tissue when coughing or sneezing;

• Use in the nearest waste receptacle to dispose of the tissue after use;

• Perform hand hygiene after having contact with respiratory secretions and contaminated objects/materials.

http:///www.cdc.gov/flu/professionals/infectioncontrol/resphygiene.htm

Supplies for Patient Areas

Kleenex

Hand sanitizer

Masks – specifications

and proper use

• Identify patients with signs and symptoms of fever and cough.

• Place symptomatic patients in separate room.

• Give patient surgical face mask

• Contact providers should wear at least surgical face mask.

http://www.health.state.mn.us/divs/idepc/dtopics/infectioncontrol/cover/hcp/notice.pdf

Safe Injection Practices

• Safe Injection Practices are a set of recommendations within Standard Precautions, which are the foundation for preventing transmission of infections during patient care in all healthcare settings

Note: In dentistry, generally applies to administration of parenteral medications not related to local anesthesia.

http://www.cdc.gov/injectionsafety/IP07_standardPrecaution.html

Risk of Infection after Needlestick

Source

HBVHBeAg+HBeAg-

HCV

HIV

Risk

6.0-30.0%22.0-30.0%

1.0-6.0%

1.8%

0.3%

1/3

1/300

1/30

Safe Injection Practices = Aseptic Technique for Parenteral Medications

• Do not administer medications from a syringe to multiple patients, even if the needle on the syringe is changed (IA) (378).

• Use single-dose vials for parenteral medications when possible (II) (376,377).

• Do not combine the leftover contents of single-use vials for later use (IA) (376,377).

• Use fluid infusion and administration sets (i.e., IV bags, tubing and connections) for one patient only and dispose of appropriately (IB) (378).

CDC 2007 Guideline for Isolation Precautionshttp://www.cdc.gov/ncidod/dhqp/pdf/isolation2007.pdf. Guidelines for infection control in dental health-care settings—2003. http://www.cdc.gov/mmwr/PDF/rr/rr5217.pdf

Environmental Surfaces

Clinical Contact Housekeeping

Environmental Stability

• HBV can survive in dried blood on environmental surfaces for at least one week.

• In vitro studies have shown the HCV can remain infective on dry surfaces for up to 6 weeks.

• HBV and HCV transmission via contact with environmental surfaces has been demonstrated in investigations of outbreaks among patients and staff of hemodialysis units.

Bond WW et al, Lancet 1981Kamili S et al, Infect Control Hosp Epidemiol 2007Paintsil E, J Infect Dis 2014.

• Remove

• Replace• Spray

• Clean/wipe

• Spray

Barriers VS. Cleaning and Disinfection

84

Clean and disinfect using an EPA registered low- ( HIV/HBV claim) to intermediate- (tuberculocidal claim) level hospital disinfectant

Premoistened Disinfectant Wipes

• Wipe (clean)

• Wipe (disinfect)

• Wait (manufacturer’s claim)

• Follow specific Product Manufacturer’s Instructions for use.

Principle 4Make Reusable Patient Care Items Safe for Use

• Clean, heat sterilize or disinfect reusable patient care items that ….

• Monitor processes….

• Contain and dispose of single use items

• Considerations for on-site vs. centralized processing of re-usable patient care items.

86

Proper Work Flow Prevents Errors

“Program evaluation provides an

opportunity to identify and change

inappropriate practices, thereby

improving the effectiveness of your

infection control program.”

• Centers for Disease Control (CDC) “Guidelines for Infection Control in Dental Health-Care Settings – 2003”

Implementing Change

Proactive

Reactive

Program Evaluation

• Strategies and Tools

–Periodic observational assessments

–Checklists to document procedures

–Routine review of occupational exposures to bloodborne pathogens

Checklists for Repeatable Processes

• Remind individuals of critical steps to complete each time

• Provide verification that the steps have been completed

• Create a history that can be reconstructed if there is an adverse event

2011

Guide and Checklist for Outpatient Settings

http://www.cdc.gov/HAI/settings/outpatient/outpatient-settings.html

2011 Guide Summary

Basic infection prevention recommendations for outpatient settings Administrative measures

• Education and training of all HCP

• Report process and outcome measures

Standard Precautions Hand hygiene PPE

Injection safety Environmental cleaning

Medical equipment Resp hygiene/cough etiquette

Resources Disinfection and sterilization

FDA device information

Transmission based precautions

Checklist for Infection Prevention for Outpatient Settings

Thank You